Healthcare Provider Details

I. General information

NPI: 1285607838
Provider Name (Legal Business Name): JOHNNY J SACCO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 STONECIPHER DR
ADA OK
74820-3439
US

IV. Provider business mailing address

1925 WARRIOR WAY
ADA OK
74820-3491
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-3980
  • Fax: 580-421-6283
Mailing address:
  • Phone: 580-421-4570
  • Fax: 580-421-6283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1079255
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number94306
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: